-
Notifications
You must be signed in to change notification settings - Fork 0
/
Copy pathIRS8885.xsl
491 lines (491 loc) · 24.1 KB
/
IRS8885.xsl
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
137
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
181
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
200
201
202
203
204
205
206
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
240
241
242
243
244
245
246
247
248
249
250
251
252
253
254
255
256
257
258
259
260
261
262
263
264
265
266
267
268
269
270
271
272
273
274
275
276
277
278
279
280
281
282
283
284
285
286
287
288
289
290
291
292
293
294
295
296
297
298
299
300
301
302
303
304
305
306
307
308
309
310
311
312
313
314
315
316
317
318
319
320
321
322
323
324
325
326
327
328
329
330
331
332
333
334
335
336
337
338
339
340
341
342
343
344
345
346
347
348
349
350
351
352
353
354
355
356
357
358
359
360
361
362
363
364
365
366
367
368
369
370
371
372
373
374
375
376
377
378
379
380
381
382
383
384
385
386
387
388
389
390
391
392
393
394
395
396
397
398
399
400
401
402
403
404
405
406
407
408
409
410
411
412
413
414
415
416
417
418
419
420
421
422
423
424
425
426
427
428
429
430
431
432
433
434
435
436
437
438
439
440
441
442
443
444
445
446
447
448
449
450
451
452
453
454
455
456
457
458
459
460
461
462
463
464
465
466
467
468
469
470
471
472
473
474
475
476
477
478
479
480
481
482
483
484
485
486
487
488
489
490
491
<?xml version="1.0" encoding="UTF-8"?>
<xsl:stylesheet xmlns:xsl="http://www.w3.org/1999/XSL/Transform" version="1.0">
<xsl:include href="PopulateTemplate.xsl"/>
<xsl:include href="CommonPathRef.xsl"/>
<xsl:include href="AddHeader.xsl"/>
<xsl:include href="AddOnTable.xsl"/>
<xsl:include href="IRS8885Style.xsl"/>
<xsl:output method="html" indent="yes"/>
<xsl:strip-space elements="*"/>
<xsl:param name="Form8885Data" select="$RtnDoc/IRS8885"/>
<!-- ////////////////////////////////////////////////////////////// (Template: PopulateBulletSpan) -->
<xsl:template name="PopulateBulletSpan">
<xsl:attribute name="style">width:100%;height:auto;padding-top:0.8mm;</xsl:attribute>
<img src="{$ImagePath}/8885_Round_Bullet.gif" alt="Round Bullet"/>
<span style="width:4px;"/>
</xsl:template>
<!-- ////////////////////////////////////////////////////////////// (Template: PopulateMonthCheckbox) -->
<xsl:template name="PopulateMonthCheckbox">
<xsl:param name="TargetNode"/>
<xsl:param name="BackupName"/>
<xsl:param name="Label"/>
<span style="width:25mm;height:auto;">
<input type="checkbox" class="styCkbox">
<xsl:call-template name="PopulateCheckbox">
<xsl:with-param name="TargetNode" select="$TargetNode"/>
<xsl:with-param name="BackupName">
<xsl:value-of select="$BackupName"/>
</xsl:with-param>
</xsl:call-template>
</input>
<span style="width:1.5mm;"/>
<label>
<xsl:call-template name="PopulateLabel">
<xsl:with-param name="TargetNode" select="$TargetNode"/>
<xsl:with-param name="BackupName">
<xsl:value-of select="$BackupName"/>
</xsl:with-param>
</xsl:call-template>
<xsl:value-of select="$Label"/>
</label>
</span>
</xsl:template>
<!-- ////////////////////////////////////////////////////////////// (Template: CreateBox) -->
<xsl:template name="CreateBox">
<xsl:param name="TargetNode"/>
<xsl:param name="AmountBoxStyle"/>
<xsl:param name="PopulateAsText"/>
<xsl:param name="StaticText"/>
<xsl:param name="Number"/>
<xsl:param name="NumberBoxStyle"/>
<xsl:param name="Width">29mm</xsl:param>
<xsl:param name="Height">5mm</xsl:param>
<div class="styLNAmountBox">
<xsl:attribute name="style">
width:<xsl:value-of select="$Width"/>;height:<xsl:value-of select="$Height"/>;
border-right-width:0px;float:right;text-align:right;padding-right:2px;font-size:7pt;
<xsl:choose><xsl:when test="$TargetNode"><xsl:choose><xsl:when test="$TargetNode/@referenceDocumentId">padding-top:2px;</xsl:when><xsl:otherwise>padding-top:4px;</xsl:otherwise></xsl:choose></xsl:when><xsl:otherwise>padding-top:3px;</xsl:otherwise></xsl:choose><xsl:if test="$AmountBoxStyle"><xsl:value-of select="$AmountBoxStyle"/></xsl:if></xsl:attribute>
<xsl:choose>
<xsl:when test="$TargetNode">
<xsl:choose>
<xsl:when test="$PopulateAsText">
<xsl:call-template name="PopulateText">
<xsl:with-param name="TargetNode" select="$TargetNode"/>
</xsl:call-template>
</xsl:when>
<xsl:otherwise>
<xsl:call-template name="PopulateAmount">
<xsl:with-param name="TargetNode" select="$TargetNode"/>
</xsl:call-template>
</xsl:otherwise>
</xsl:choose>
<xsl:if test="$TargetNode/@referenceDocumentId">
<xsl:call-template name="SetFormLinkInline">
<xsl:with-param name="TargetNode" select="$TargetNode"/>
</xsl:call-template>
</xsl:if>
</xsl:when>
<xsl:when test="$StaticText">
<xsl:value-of select="$StaticText"/>
</xsl:when>
</xsl:choose>
</div>
<div class="styLNRightNumBox">
<xsl:attribute name="style">
float:right;
padding:2px 0px 0px 0px;
border-right-width:0px;font-size:8pt;
height:<xsl:value-of select="$Height"/>;
<xsl:if test="$NumberBoxStyle"><xsl:value-of select="$NumberBoxStyle"/></xsl:if></xsl:attribute>
<xsl:if test="$Number">
<xsl:value-of select="$Number"/>
</xsl:if>
</div>
</xsl:template>
<!-- /////////////////////////////////////////////////////////////////////////////////////////////////////// -->
<xsl:template match="/">
<html lang="EN-US">
<head>
<title>
<xsl:call-template name="FormTitle">
<xsl:with-param name="RootElement" select="local-name($Form8885Data)"/>
</xsl:call-template>
</title>
<!-- No Browser Caching -->
<meta http-equiv="Pragma" content="no-cache"/>
<meta http-equiv="Cache-Control" content="no-cache"/>
<meta http-equiv="Expires" content="0"/>
<!-- No Proxy Caching -->
<meta http-equiv="Cache-Control" content="private"/>
<!-- Define Character Set -->
<meta http-equiv="Content-Type" content="text/html; charset=ISO-8859-1"/>
<meta name="Description" content="IRS Form 8885"/>
<script language="JavaScript" src="{$ScriptPath}/FormDisplay.js" type="text/javascript"/>
<xsl:call-template name="InitJS"/>
<style type="text/css">
<xsl:if test="not($Print) or $Print=''">
<xsl:call-template name="IRS8885Style"/>
<xsl:call-template name="AddOnStyle"/>
</xsl:if>
</style>
<xsl:call-template name="GlobalStylesForm"/>
</head>
<body class="styBodyClass">
<form name="IRS8885">
<!-- Begin Header section 1 -->
<xsl:call-template name="DocumentHeader"/>
<div class="styBB" style="width:187mm;border-bottom-width:2px;">
<div class="styFNBox" style="width:31mm;height:22mm;border-right-width:2px;padding-top:.5mm;">
<div style="padding-top:1mm;">
Form<span class="styFormNumber"> 8885</span>
</div>
<!--General Dependency Push Pin-->
<xsl:call-template name="SetFormLinkInline">
<xsl:with-param name="TargetNode" select="$Form8885Data"/>
</xsl:call-template>
<br/>
<span class="styAgency">Department of the Treasury</span>
<br/>
<span class="styAgency">Internal Revenue Service</span>
</div>
<div class="styFTBox" style="width:125mm;">
<!-- Main Title >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> -->
<div class="styMainTitle" style="height:8mm;">
<br/>
Health Coverage Tax Credit
</div>
<div class="styFST" style="height:5mm;font-size:7pt;margin-left:2mm;text-align:center;">
<span style="text-align:center;font-weight:bold;">
<div style="width:100%;height:5mm;padding-left:5px;">
<div style="width:100%;height:5mm;">
<br/>
<br/>
<img src="{$ImagePath}/8885_Bullet_Sm.gif" alt="SmallBullet"/>
Attach to Form 1040, Form 1040NR, Form 1040-SS, or Form 1040-PR.
</div>
</div>
</span>
</div>
</div>
<div class="styTYBox" style="width:30mm;border-left-width:2px;">
<div class="styOMB" style="height:2mm;font-size:7pt;">OMB No. 1545-0074</div>
<div class="styTY">20<span class="styTYColor">12</span>
</div>
<div style="margin-left:3mm;text-align:left;font-size:7pt;">
Attachment<br/>Sequence No.
<span class="styBoldText" style="font-size:9pt;">134</span>
</div>
</div>
</div>
<!-- End Header section 1 -->
<!-- Begin Names and Identifying number section -->
<div class="styTBB" style="width:187mm;">
<div class="styNameBox" style="width:137mm;height:8mm;font-weight:normal;font-size:7pt;">
Name of recipient (if both spouses are recipients, complete a separate form for each spouse)<br/>
<xsl:choose>
<xsl:when test="$Form8885Data/PersonName">
<xsl:call-template name="PopulateText">
<xsl:with-param name="TargetNode" select="$Form8885Data/PersonName"/>
</xsl:call-template>
</xsl:when>
<xsl:otherwise>
<xsl:call-template name="PopulateText">
<xsl:with-param name="TargetNode" select="$RtnHdrData/Filer/Name"/>
</xsl:call-template>
</xsl:otherwise>
</xsl:choose>
</div>
<div style="height:8mm;width:50mm;height:4mm;padding:0px 0px 0px 2mm;font-size:7pt;" class="styEINBox">
Recipient's social security number
<br/>
<span style="font-weight:normal;text-align:center;width:100%">
<xsl:call-template name="PopulateSSN">
<xsl:with-param name="TargetNode" select="$Form8885Data/RecipientsSSN"/>
</xsl:call-template>
</span>
</div>
</div>
<!-- End Names and Identifying number section -->
<div class="styTBB" style="width:187mm">
<div class="styIRS8885LineItem">
<div class="styIRS8885LNDesc" style="width:100%;padding-left:0px;font-size:9pt;">
<span class="styItalicText" style="font-weight:bold;">Before you begin: </span>
See <b>Definitions and Special Rules</b> in the instructions.
</div>
</div>
</div>
<div class="styTBB" style="width:187mm">
<div class="styIRS8885LineItem" style="padding-top:1.5mm;padding-bottom:1mm;">
<div class="styIRS8885CleanDiv" style="height:100%;width:auto;">
<img src="{$ImagePath}/8885_Caution.gif" alt="Caution"/>
</div>
<div class="styIRS8885LNDesc" style="width:auto;height:100%;padding-top:6.5mm;">
<b>Do not </b>complete this form if you can be claimed as a dependent on someone else's 2012 tax return.
</div>
</div>
</div>
<!-- >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> -->
<!-- Begin Part I -->
<!-- <<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< -->
<!-- Header -->
<div style="width:187mm;padding:0px 0px 0px 0px;" class="styBB">
<!-- Content -->
<div class="styPartName" style="width:15mm;">Part I</div>
<div class="styPartDesc" style="padding-left:3mm;font-size:8.5pt;">
Complete This Part To See if You Are Eligible To Take This Credit
</div>
</div>
<!-- Body -->
<div class="styBB" style="width:187mm;">
<!-- (1) ////////////////////////////////////////////////////-->
<div class="styIRS8885LineItem">
<div class="styIRS8885LNLeftNumBox">1</div>
<div class="styIRS8885LNDesc" style="width:181mm;height:100%;">
Check the boxes below for each month in 2012 that <b>all</b> of the following statements were <b>true</b> on the <b>first day</b> of that month.<br/>
<span>
<xsl:call-template name="PopulateBulletSpan"/>
You were an eligible trade adjustment assistance (TAA) recipient, alternative TAA (ATAA) recipient, reemployment TAA (RTAA) <br/>
recipient, or Pension Benefit Guaranty Corporation (PBGC) pension payee; or you were a qualified family member of an <br/>
individual who fell under one of the categories listed above when he or she passed away or with whom you finalized<br/>
a divorce.
</span>
<span>
<xsl:call-template name="PopulateBulletSpan"/>
You and/or your family member(s) were covered by a qualified health insurance plan for which you paid the entire premiums, <br/>
or your portion of the premiums, directly to your health plan or to "U.S. Treasury–HCTC."
</span>
<span>
<xsl:call-template name="PopulateBulletSpan"/>
You were <b>not</b> enrolled in Medicare Part A, B, or C, or you were enrolled in Medicare but your family member(s) qualified for <br/>
the HCTC.
</span>
<span>
<xsl:call-template name="PopulateBulletSpan"/>
You were <b>not</b> enrolled in Medicaid or the Children's Health Insurance Program (CHIP).
</span>
<span>
<xsl:call-template name="PopulateBulletSpan"/>
You were <b>not</b> enrolled in the Federal Employees Health Benefits Program (FEHBP) or eligible to receive benefits under the <br/>
U.S. military health system (TRICARE).
</span>
<span>
<xsl:call-template name="PopulateBulletSpan"/>
You were <b>not</b> imprisoned under federal, state, or local authority.
</span>
<span>
<xsl:call-template name="PopulateBulletSpan"/>
Your employer <b>did not</b> pay 50% or more of the cost of coverage.
</span>
<span>
<xsl:call-template name="PopulateBulletSpan"/>
You <b>did not</b> receive a 65% COBRA premium reduction from your former employer or COBRA administrator.
</span>
<span style="width:100%;height:5mm;"/>
<span style="width:2mm;"/>
<!-- January -->
<xsl:call-template name="PopulateMonthCheckbox">
<xsl:with-param name="TargetNode" select="$Form8885Data/HealthCvrTaxCrJanuaryInd"/>
<xsl:with-param name="BackupName">IRS8885HealthCvrTaxCrJanuaryInd</xsl:with-param>
<xsl:with-param name="Label">January</xsl:with-param>
</xsl:call-template>
<!-- February -->
<xsl:call-template name="PopulateMonthCheckbox">
<xsl:with-param name="TargetNode" select="$Form8885Data/HealthCvrTaxCrFebruaryInd"/>
<xsl:with-param name="BackupName">IRS8885HealthCvrTaxCrFebruaryInd</xsl:with-param>
<xsl:with-param name="Label">February</xsl:with-param>
</xsl:call-template>
<!-- March -->
<xsl:call-template name="PopulateMonthCheckbox">
<xsl:with-param name="TargetNode" select="$Form8885Data/HealthCvrTaxCrMarchInd"/>
<xsl:with-param name="BackupName">IRS8885HealthCvrTaxCrMarchInd</xsl:with-param>
<xsl:with-param name="Label">March</xsl:with-param>
</xsl:call-template>
<!-- April -->
<xsl:call-template name="PopulateMonthCheckbox">
<xsl:with-param name="TargetNode" select="$Form8885Data/HealthCvrTaxCrAprilInd"/>
<xsl:with-param name="BackupName">IRS8885HealthCvrTaxCrAprilInd</xsl:with-param>
<xsl:with-param name="Label">April</xsl:with-param>
</xsl:call-template>
<!-- May -->
<xsl:call-template name="PopulateMonthCheckbox">
<xsl:with-param name="TargetNode" select="$Form8885Data/HealthCvrTaxCrMayInd"/>
<xsl:with-param name="BackupName">IRS8885HealthCvrTaxCrMayInd</xsl:with-param>
<xsl:with-param name="Label">May</xsl:with-param>
</xsl:call-template>
<!-- June -->
<xsl:call-template name="PopulateMonthCheckbox">
<xsl:with-param name="TargetNode" select="$Form8885Data/HealthCvrTaxCrJuneInd"/>
<xsl:with-param name="BackupName">IRS8885HealthCvrTaxCrJuneInd</xsl:with-param>
<xsl:with-param name="Label">June</xsl:with-param>
</xsl:call-template>
<br/>
<span style="width:100%;"/>
<span style="width:2mm;"/>
<!-- July -->
<xsl:call-template name="PopulateMonthCheckbox">
<xsl:with-param name="TargetNode" select="$Form8885Data/HealthCvrTaxCrJulyInd"/>
<xsl:with-param name="BackupName">IRS8885HealthCvrTaxCrJulyInd</xsl:with-param>
<xsl:with-param name="Label">July</xsl:with-param>
</xsl:call-template>
<!-- August -->
<xsl:call-template name="PopulateMonthCheckbox">
<xsl:with-param name="TargetNode" select="$Form8885Data/HealthCvrTaxCrAugustInd"/>
<xsl:with-param name="BackupName">IRS8885HealthCvrTaxCrAugustInd</xsl:with-param>
<xsl:with-param name="Label">August</xsl:with-param>
</xsl:call-template>
<!-- September -->
<xsl:call-template name="PopulateMonthCheckbox">
<xsl:with-param name="TargetNode" select="$Form8885Data/HealthCvrTaxCrSeptemberInd"/>
<xsl:with-param name="BackupName">IRS8885HealthCvrTaxCrSeptemberInd</xsl:with-param>
<xsl:with-param name="Label">September</xsl:with-param>
</xsl:call-template>
<!-- October -->
<xsl:call-template name="PopulateMonthCheckbox">
<xsl:with-param name="TargetNode" select="$Form8885Data/HealthCvrTaxCrOctoberInd"/>
<xsl:with-param name="BackupName">IRS8885HealthCvrTaxCrOctoberInd</xsl:with-param>
<xsl:with-param name="Label">October</xsl:with-param>
</xsl:call-template>
<!-- November -->
<xsl:call-template name="PopulateMonthCheckbox">
<xsl:with-param name="TargetNode" select="$Form8885Data/HealthCvrTaxCrNovemberInd"/>
<xsl:with-param name="BackupName">IRS8885HealthCvrTaxCrNovemberInd</xsl:with-param>
<xsl:with-param name="Label">November</xsl:with-param>
</xsl:call-template>
<!-- December -->
<xsl:call-template name="PopulateMonthCheckbox">
<xsl:with-param name="TargetNode" select="$Form8885Data/HealthCvrTaxCrDecemberInd"/>
<xsl:with-param name="BackupName">IRS8885HealthCvrTaxCrDecemberInd</xsl:with-param>
<xsl:with-param name="Label">December</xsl:with-param>
</xsl:call-template>
<span style="width:100%;height:2mm;"/>
</div>
</div>
</div>
<!-- >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> -->
<!-- Begin Part II -->
<!-- <<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< -->
<!-- Header -->
<div style="width:187mm;padding:0px 0px 0px 0px;" class="styBB">
<!-- Content -->
<div class="styPartName" style="width:15mm;">Part II</div>
<div class="styPartDesc" style="padding-left:3mm;font-size:8.5pt;">
Health Coverage Tax Credit
</div>
</div>
<!-- Body -->
<!-- (Column Headers) ////////////////////////////////////////////////////-->
<!-- (2) //////////////////////////////////////////////////-->
<div class="styGenericDiv" style="height:14mm;width:187mm;">
<div class="styLNLeftNumBoxSD" style="height:100%;width:6mm">2</div>
<div class="styGenericDiv" style="padding-left:2mm;padding-right:1mm;width:138.6mm;padding-top:0.5mm;">
Enter the total amount paid directly to your health plan for qualified health insurance coverage for <br/>
the months checked on line 1 (see instructions). <b>Do not</b> include on line 2 any qualified health <br/>
insurance premiums paid to "U.S. Treasury–HCTC" or any insurance premiums on coverage that <br/>
was actually paid for with a National Emergency Grant. Also, <b>do not</b> include any advance (monthly) <br/>
<span style="float:left;">payments or reimbursement credits you received shown on Form 1099-H, box 1</span>
<!--Dotted Line-->
<span class="styBoldText" style="float:right;letter-spacing:12px;padding-right:3mm;">.......</span>
</div>
<div class="styLNRightNumBox" style="height:14mm;"><br/><br/><br/><br/>2</div>
<div class="styLNAmountBox" style="height:14mm;width:34mm;"><br/><br/><br/><br/>
<xsl:call-template name="PopulateAmount">
<xsl:with-param name="TargetNode" select="$Form8885Data/HealthPlanPaidAmt"/>
</xsl:call-template>
</div>
</div>
<!-- (Caution) ////////////////////////////////////////////////////-->
<div class="styGenericDiv" style="width:187mm;height:15mm;">
<div class="styLNLeftNumBoxSD" style="width:6mm"/>
<div class="styGenericDiv" style="padding-left:2mm;width:20mm;">
<img src="{$ImagePath}/8863_Caution.gif" alt="Caution" width="50" height="50"/>
</div>
<div class="styGenericDiv" style="padding-left:0mm;padding-top:2mm;width:118.5mm;">
<span class="styItalicText">
You <b>must</b> attach the required documents listed in the instructions for any
amounts included on line 2. If you do not attach the required documents,
your credit will be disallowed.
</span>
</div>
<div class="styLNRightNumBox" style="height:15mm;border-bottom-width:0"/>
<div class="styLNAmountBox" style="height:15mm;width:34mm;padding-bottom:0;border-bottom-width:0">
</div>
</div>
<!--(3) /////////////////////////////////////////////////// -->
<div class="styGenericDiv" style="width:187mm;">
<div class="styLNLeftNumBoxSD" style="height:100%;width:6mm">3</div>
<div class="styGenericDiv" style="padding-left:2mm;padding-right:1mm;width:138.6mm;padding-top:0.5mm;">
Enter the total amount of any Archer MSA or health savings accounts distributions used to pay for <br/>
<span style="float:left;">qualified health insurance coverage for the months checked on line 1</span>
<!--Dotted Line-->
<span class="styBoldText" style="float:right;letter-spacing:12px;padding-right:3mm;">...........</span>
</div>
<div class="styLNRightNumBox" style=""><br/>3</div>
<div class="styLNAmountBox" style="width:34mm"><br/>
<xsl:call-template name="PopulateAmount">
<xsl:with-param name="TargetNode" select="$Form8885Data/HealthPlanPaidWithMSAOrHSAAmt"/>
</xsl:call-template>
</div>
</div>
<!-- (4) //////////////////////////////////////////////////// -->
<div class="styGenericDiv" style="width:187mm;">
<div class="styLNLeftNumBoxSD" style="width:6mm">4</div>
<div class="styGenericDiv" style="padding-left:2mm;padding-right:1mm;width:138.6mm;padding-top:0.5mm;">
<span style="float:left;">Subtract line 3 from line 2. If zero or less, <b>stop</b>; you cannot take the credit</span>
<!--Dotted Line-->
<span class="styBoldText" style="float:right;letter-spacing:12px;padding-right:3mm;">.........</span>
</div>
<div class="styLNRightNumBox" style="">4</div>
<div class="styLNAmountBox" style="width:34mm">
<xsl:call-template name="PopulateAmount">
<xsl:with-param name="TargetNode" select="$Form8885Data/HealthPlanPaidLessMSAAndNEGAmt"/>
</xsl:call-template>
</div>
</div>
<!-- (5) ///////////////////////////////////////////////////-->
<div class="styGenericDiv" style="width:187mm;border-bottom:1px solid black;">
<div class="styLNLeftNumBoxSD" style="width:6mm">5</div>
<div class="styGenericDiv" style="padding-left:2mm;padding-right:1mm;width:138.6mm;padding-top:0.5mm;">
<b>Health Coverage Tax Credit.</b> If you received an advance (monthly) payment in any month not <br/>
checked on line 1, see the instructions for line 5 for more details. Otherwise, multiply the amount <br/>
on line 4 by 72.5% (.725). Enter the result here and on Form 1040, line 71 (check box d); Form <br/>
<span style="float:left;">1040NR, line 67 (check box d); Form1040-SS, line 9; or Form 1040-PR, line 9</span>
<!--Dotted Line-->
<span class="styBoldText" style="float:right;letter-spacing:12px;padding-right:3mm;">.......</span>
</div>
<div class="styLNRightNumBox" style="border-bottom-width:0;"><br/><br/><br/>5</div>
<div class="styLNAmountBox" style="width:34mm;border-bottom-width:0;"><br/><br/><br/>
<xsl:call-template name="PopulateAmount">
<xsl:with-param name="TargetNode" select="$Form8885Data/HealthCoverageTaxCreditAmt"/>
</xsl:call-template>
</div>
</div>
<!-- <<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< -->
<!-- Page Break and Footer-->
<div class="pageEnd" style="width:187mm;padding-top:1mm;">
<div style="float:left;">
<span class="styBoldText">
For Paperwork Reduction Act Notice, see your tax return instructions.
</span>
</div>
<div style="float:right;">
<span style="width:50px;"/>
Form
<span class="styBoldText" style="font-size:8pt;">8885</span> (2012)
</div>
<div style="float:right;text-align:center;width:26mm;font-size:7pt;">
Cat. No. 34641D
</div>
</div>
<!-- <<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< -->
<!-- Additonal Data Title Bar and Button -->
<div class="styLeftOverTitleLine" id="LeftoverData" style="padding-top:5mm;">
<div class="styLeftOverTitle">
Additional Data
</div>
<div class="styLeftOverButtonContainer">
<input class="styLeftoverTableBtn" type="button" TabIndex="-1" value="Return to Form" onclick="javascript:returnToWriteInImage();"/>
</div>
</div>
<!-- Additional Data Table -->
<xsl:variable name="TableWidth">100</xsl:variable>
<table class="styLeftOverTbl">
<xsl:call-template name="PopulateCommonLeftover">
<xsl:with-param name="TargetNode" select="$Form8885Data"/>
<xsl:with-param name="DescWidth" select="$TableWidth"/>
</xsl:call-template>
</table>
</form>
</body>
</html>
</xsl:template>
</xsl:stylesheet>